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In the interventional treatment of tricuspid valve regurgitation, the majority of prosthetic devices interact with or are implanted to the tricuspid valve annulus. For new transcatheter technologies, there exists a growing body of clinical experience, literature, and professional discourse related to the difficulties in delivering, securing, and sustaining the function of these devices within the dynamic tricuspid annulus. Many of the difficulties arise from circumstances not encountered in open-heart surgery, namely; a non-arrested heart, indirect visualization, and a reliance on non-suture-based methods. These challenges require the application of procedural techniques or system designs to account for tricuspid annular motion, forces, and underlying tissue strength. Improved knowledge in these interactions will support the goals of improving device systems, their procedures, and patient outcomes. This review aims to describe current concepts of tricuspid annular mechanics, key device and procedural implications, and highlight current knowledge gaps for future consideration.

Objectives Although aortic annulus repair has a long history, there are still no ideal devices to control an aortic annulus. We have developed a new method involving the use of an expanded polytetrafluoroethylene graft with the support of a metallic ring holder during implantation from inside an aorta, with no dissection of the surrounding aortic annulus. Methods We used aortic annular rings of 18 to 24 mm made of Gore-Tex tubed grafts (W.L. Gore & Associates, Flagstaff, AZ, USA) and metallic ring holder. After cutting the graft circumferentially to a 5-mm thickness, it was compressed manually to decrease the thickness. Then, a metallic ring holder corresponding to the graft size was inserted into the graft. The metallic ring holder was fixed to the graft with one 4–0 monofilament suture using 6 holes and the side trench on the metallic ring holder. The proper size for the graft was determined, and the appropriate annuloplasty ring was selected. A row of 4–0 double-needle braided sutures with expanded polytetrafluoroethylene spaghettis was sewn from the aortic side into the left ventricular outflow tract with a horizontal mattress stitch. After all sutures around the annulus were placed, they were tied down and the metallic ring holder was removed. The leaflets were repaired if necessary. Results A total of 9 patients with tricuspid aortic valve have undergone this procedure since January 2015. The sizes of the aortic annular rings were 20 mm ( n = 3), 22 mm ( n = 5), and 24 mm ( n = 2). Aortic leaflets were repaired in 6 patients (6 central plications). Concomitant procedures were total aortic arch replacement ( n = 2), mitral valve repair ( n = 2), tricuspid valve repair ( n = 1), and coronary artery bypass grafting ( n = 2). There were no hospital deaths and no major morbidities. All patients were checked for mild or less than mild aortic regurgitation during the mean follow-up period of 13 months. Postoperative echocardiograms showed excellent peak pressure gradients compared with preoperative echocardiograms. Postoperative cardiac computed tomography scans were performed in 6 patients. The discrepancies between the ring size used and postoperative annular size were Conclusions This new flexible ring is easy to use to fix an aortic annulus from the inside. Early results reveal excellent control of aortic regurgitation with the projected annular size. Further investigations are needed to ensure the effectiveness of the ring.

Valve preservation or repair of the regurgitant bicuspid aortic valve (BAV) minimizes valve-related complications. The purpose of the current analysis was to determine the proportion of BAVs than can be repaired. Between 2000 and 9/2018, 1168 operations for BAV without stenotic pathology were performed. Of these, 103 underwent isolated aortic valve replacement, the remaining 1055 individuals underwent valve repair. Reasons for replacement were analyzed. The proportion of repaired BAVs remained constant at 85% over the years. The most frequent reasons for replacement were cusp calcification or active endocarditis. In only 2 instances, replacement was performed as intraoperative conversion after failed repair. The vast majority of BAVs can be repaired with good durability as long as cusp substance is preserved.

Objective Aortic valve repair is currently in transition from surgical improvisation to a reproducible operation and an option for many patients with aortic regurgitation. Our research efforts at improving reproducibility include development of methods for intraoperatively testing and visualizing the valve in its diastolic state. Methods We developed a device that can be intraoperatively secured in the transected aorta allowing the aortic root to be pressurized and the closed valve to be inspected endoscopically. Our device includes a chamber that can be pressurized with crystalloid solution and ports for introduction of an endoscope and measuring gauges. We show use of the device in explanted porcine hearts to visualize the aortic valve and to measure leaflet coaptation height in normal valves and in valves that have undergone valve repair procedures. Results The procedure of introducing and securing the device in the aorta, pressurizing the valve, and endoscopically visualizing the closed valve is done in less than 1 minute. The device easily and reversibly attaches to the aortic root and allows direct inspection of the aortic valve under conditions that mimic diastole. It enables the surgeon to intraoperatively study the valve immediately before repair to determine mechanisms of incompetence and immediately after the repair to assess competence. We also show its use in measuring valve leaflet coaptation height in the diastolic state. Conclusions This device enables more relevant prerepair valve assessment and also enables a test of postrepair valve competence under physiological pressures.

Purpose: Different surgical procedures were defined due to degree of Ebstein anomaly. In this study, we are reporting our surgical experience of adult patients with Ebstein anomaly. Methods: We analyzed the patients, who had operated with the diagnosis of Ebstein anomaly from March 2011 through February 2018, retrospectively. We evaluated patients in two groups: patients with cone type surgical repair were in Group 1 and patients with other surgical (Danielson, Carpentier) procedures were in Group 2. Results: There were 23 patients in the study; 9 (39%) were in Group 1 and 14 (61%) were in Group 2. In the comparison of preoperative data, groups were statistically similar. Aortic cross clamp and cardiopulmonary bypass (CPB) times, need for inotropic agents, intubation time, postoperative >2 tricuspid regurgitation incidence, intensive care unit, and hospital staying times were statistically significantly higher in Group 2. There was one mortality (4.3%) in Group 2 due to sepsis. Conclusion: Cone type repair can safely be performed in the repair of Ebstein anomaly with acceptable results. Our results are encouraging to prefer this technique as one of the first-line treatment of Ebstein anomaly. However, further randomized controlled studies are recommended to evaluate the efficacy of this surgical procedure.

Surgical annuloplasty for functional tricuspid regurgitation (FTR) is on the rise and can be performed in several ways with varied outcomes. In this study, we sought to compare the hemodynamic outcomes of tricuspid annuloplasty performed with a commercially available annuloplasty ring (tricuspid valve annuloplasty [TVA]) compared with focal suture annuloplasty (Hetzer) in an experimental FTR model.An ex vivo FTR model was developed by inducing right ventricular dilatation by acute afterload elevation, causing severe tricuspid valve tethering and annular dilatation, leading to regurgitation. Ten porcine hearts in which FTR was induced underwent TVA with a 26-mm Edwards MC3 ring and Hetzer annuloplasty with a pledgeted suture cinching the anteroposterior and septal annulus. FTR was measured before after each repair, and tenting geometry, valve kinematics, and subvalvular geometry were measured with echocardiography.At baseline, none of the hearts had FTR, but upon afterload elevation an FTR volume of 17.7 ± 9.2 mL (26.38 ± 17.47% regurgitant fraction) was measured (P .0001). TVA reduced regurgitation by 50% and Hetzer annuloplasty by 56% , respectively, but both left persistent FTR. Anteroseptal tenting area was 279.0 ± 158.9 mmTricuspid annuloplasty with a ring or a focal suture can reduce FTR but not eliminate it. Annular approaches did not relieve tricuspid valve tethering and reduced leaflet mobility persisted. Either subannular repairs or judicious use of valve replacement may be necessary.

Quadricuspid aortic valve (QAV) is a rare congenital anomaly often associated with aortic insufficiency. The exact anatomy of QAV is variable, and most cases have undergone aortic valve replacement. With the recognition that aortic valve repair achieves superior patient outcomes as compared to replacement, a systematic approach to autologous reconstruction of QAV is needed. This article reports 2 cases having successful repair utilizing geometric aortic annuloplasty rings, and describes a proposed scheme for repairing most QAV defects, based on relative leaflet and commissural characteristics. Using either tri-leaflet or bicuspid ring annuloplasty, the normal sub-commissural triangles can be remodeled into a 120° or 180° configuration, respectively, and then the leaflets can be sutured and plicated to fit annular geometry. With this approach, most quadricuspid valves potentially could undergo autologous reconstruction.

Although De Vega annuloplasty is an important option for pediatric patients with functional tricuspid regurgitation (TR), little is known about its long-term results, including the future of the plicated annulus. We retrospectively reviewed our experience with pediatric patients who underwent the De Vega annuloplasty between 2005 and 2020. Tricuspid valve assessments were performed by transthoracic echocardiography. The targeted diameter of annular plication was 80 to 90% of normal tricuspid diameter, according to the patient's condition. The study included 55 patients (41 with biventricular physiology (group B), 14 with univentricular physiology (group U)) with a median follow-up of 5.0 years. Median age at operation was 5.0 years. There was one late death due to severe mitral regurgitation. Tricuspid valve reoperation was required in five patients and the 10-year freedom from reoperation was 91.9% for the entire cohort. The 10-year freedom from the composite adverse outcome of death, reoperation, and significant TR was 79.2% in group B versus 56.6% in group U (p = 0.034). TR grade significantly decreased after surgery (p

Background Studies on the management of functional tricuspid regurgitation (TR) during mitral valve operations have drawn inconsistent conclusions. This study was designed to compare the treatment strategy of concomitant tricuspid annuloplasty (TAP) against isolated mitral valve replacement (MVR) in rheumatic mitral valve disease patients, and to assess the effect of concomitant TAP on postoperative right ventricular (RV) remodeling and function. Methods One hundred-seventy patients with rheumatic mitral valve disease receiving MVR were categorized into TAP group (n = 124) and non-TAP group (n = 46). Clinical and echocardiographic data were collected preoperatively and at 1-year follow-up. Three-dimensional echocardiographic indices of RV geometry and function were analyzed. Results At baseline, concomitant TAP group had larger RV end-diastolic volume, more decreased RV ejection fraction and RV longitudinal strain than non-TAP group (all P P P P P = 0.025). Conclusions Our results suggest that concomitant TAP could improve RV remodeling and function for rheumatic mitral valve disease patients, while those with mild preoperative functional TR who had isolated MVR might experience RV dilation and deterioration of RV function at follow-up. Concomitant surgery for functional TR could be considered for patients undergoing MVR with rheumatic mitral valve disease.

The incompetent bicuspid aortic valve (BAV) can be replaced or repaired using various surgical techniques. This study sought to assess the efficacy of external annuloplasty and postoperative reverse remodelling using cardiac magnetic resonance (CMR) and compare the results of external and subcommissural annuloplasty.Out of a total of 200 BAV repair performed between 2004 and 2018, 21 consecutive patients (median age 54 years) with regurgitation requiring valve repair with annuloplasty without concomitant aortic root surgery were prospectively referred for CMR and transthoracic echocardiography (TTE) one year after the operation. Two aortic annulus stabilization techniques were used: external, circumferential annuloplasty (EA), and subcommissural annuloplasty (SCA).11 patients received EA and 10 patients were treated using SCA. There was no in-hospital mortality and all patients survived the follow-up period (median: 12.6 months (first quartile: 6.6; third quartile: 14.1). CMR showed strong correlation between postoperative aortic recurrent regurgitant fraction and left ventricular end-diastolic volume (r = 0.62; p = 0.003) as well as left ventricular ejection fraction (r = -0.53; p = 0.01). Patients treated with EA as compared with SCA had larger anatomic aortic valve area measured by CMR (3.5 (2.5; 4.0) vs. 2.5 cmThe repair of the bicuspid aortic valve provides significant postoperative reverse remodelling, provided no recurrent regurgitation and durable reduction annuloplasty can be achieved. EA is associated with lower transvalvular gradients and higher aortic valve area assessed by CMR, compared to SCA.

INTRODUCTION Minimally invasive aortic valve replacement is becoming a standard treatment. The possibility of extending this approach to more demanding aortic root pathologies is being debated with limited evidence. Attaining comfort in a complex aortic repair is a "dogma" that should always be achieved. Perhaps, the patient's condition, the aortic anatomy and the expertise creates the fundamental principles that achieve stable results over time. EVIDENCE ACQUISITION Selection of literature articles was performed using PubMed databases from inception to July 2020. We excluded editorials and expert opinions, review articles, congenital heart disease, and other types of valve repair. According to the limited studies available, case reports were included. EVIDENCE SYNTHESIS We identified 7 studies from 2015 to 2020 with the number of patients spanning 1 to 117 from single centers' experiences. Three were case reports with aortic repair of a bicuspid aortic valve. A total of 259 mini-AVr patients were analyzed. CONCLUSIONS In this review article, we sought to analyze and report the experience and results of a currently available series on aortic valve repair (with or without associated aortic root procedures) using mini sternotomy. Early- and long-term data will be reported and discussed in terms of survival and aortic valve function.

Anxiety can contribute to poor prognosis in cardiac patients. Few studies have examined the role of optimism in anxiety after open heart surgery (OHS). This study investigated the influence of preoperative optimism on post-OHS anxiety, adjusting cardiac indices used by cardiac surgeons. Data were collected before and 1 month after OHS in 481 patients (58% men; age, 62.4 ± 11.94 years). Optimism was measured using the Life Orientation Test. Anxiety was measured using the Trait Anxiety Inventory. Medical and cardiac indices were retrieved from the Society of Thoracic Surgeon's national database. Multiple regression analyses showed that greater pre-OHS optimism was associated with lower levels of post-OHS anxiety (F[6, N = 306] = 50.18, p0.001, R = 0.502). No other factors showed similar protection. Pre-OHS anxiety, younger age, and minority status were associated with anxiety in the critical recovery month. The findings demonstrate the potential benefit of optimism against post-OHS anxiety, which may have clinical implications for improving disease management.

Background Liver stiffness (LS) assessed by transient elastography is associated with adverse events in patients with heart failure. However, the predictive value of LS for adverse outcome is uncertain in patients undergoing tricuspid annuloplasty (TA). This study sought to evaluate the prognostic value and reversibility of LS in patients undergoing TA during left-sided valve surgery. Methods and results A total of 158 patients who underwent TA were prospectively evaluated. Patients were divided into three groups according to tertile of LS. Adverse outcome was defined as heart failure that required hospital admission or all-cause mortality following TA. The median LS was 13.9 (inter-quartile range 8.1–22.3) kPa and independently correlated positively with tricuspid regurgitation (TR) severity, inferior vena cava diameter and negatively with tricuspid annular plane systolic excursion. During a median follow-up of 31 months, 49 adverse events occurred. Multivariable Cox regression analysis revealed that LS was an independent predictor of adverse events. Significant improvement in LS at 1-year post-TA (13.1–7.8 kPa, P Conclusions This study demonstrated that LS is predictive of adverse outcome and is reversible in patients undergoing TA without TR recurrence at 1 year. These findings suggest that assessing LS, an integrative correlate of right heart condition, may aid the pre-operative risk assessment of candidate for heart surgery including TA.

Standardization of aortic valve repair techniques with use of a calibrated annuloplasty have led to improved long-term outcomes in dystrophic aortic insufficiency. It can also improve dissemination of techniques and rates of aortic valve repair. Dystrophic aortic insufficiency can be found in three aortic phenotypes: dilated aortic root, dilated ascending aorta and isolated aortic insufficiency. The aortic annulus is invariably dilated above 25 mm in the vast majority of cases of aortic insufficiency, regardless of whether the aorta is dilated or not. A dilated annulus is a risk factor for late failure of aortic valve repair if not addressed at the time of surgery. We perform a calibrated annuloplasty at both sub- and supra-valvular levels in order to restore the ratio of sinotubular junction and annulus. Current evidence shows aortic valve repair reduces valve-related mortality compared to prosthetic valve replacement, with an improved quality of life.

Robotic cardiac surgery addressing the mitral and tricuspid valves is a highly developed field offering multiple potential advantages regarding postoperative complications, valve repair rates, hospital length of stay, and rapid functional recovery compared with the conventional sternotomy approach for select patients. The unparalleled stereoscopic view within the heart and precision of robotic arms make robotic surgery a highly attractive minimally invasive approach, facilitating repair of even the most complex valvular pathology. Careful candidate selection and surgical planning are paramount to optimising the outcomes of those who undergo robotic valve surgery. As a team’s experience grows, the technique can be applied to a wider range of patients that may derive even greater benefit, such as those with significant comorbid conditions, ventricular dysfunction, and previous sternotomy. The goal of this review is to provide clinicians with a practical overview of the factors influencing a patient’s candidacy for robotic valve surgery. We discuss key issues such as preoperative diagnostic assessment, concerns regarding demographics and surgical pathology, and additional considerations relating to surgical exposure, cardiopulmonary bypass, and myocardial protection. Diligent patient assessment and a strong team-based approach are paramount to developing and maintaining a successful robotic valve surgery program, with the most seasoned teams being able to safely offer the technique to the vast majority of patients referred for mitral or tricuspid valve repair or replacement.

Annuloplasty is essential in aortic valve repair. The most appropriate technique is highly controversial, however. We aimed to evaluate changes in postoperative annulus diameter on serial echocardiography after external and internal suture annuloplasty.We retrospectively reviewed serial transthoracic echocardiography of consecutive patients from our institutional aortic valve repair registry who had received suture annuloplasty. Midsystolic annulus diameter was measured on parasternal long-axis view preoperatively, at discharge, 3-6 months, and at 1, 2 and 3 years postoperatively. Primary endpoint was the prevalence of annulus redilatation. Secondary endpoints were the correlation between annulus redilatation and (1) external vs internal technique and (2) reoccurrence of aortic insufficiency ≥2.A total of 70 patients (mean ± SD age: 43 ± 13 years, 91% male) underwent aortic valve repair including external (n = 27) or internal (n = 43) suture annuloplasty between February 2016 and November 2019. Mean follow-up was 17 ± 11 (range: 3-50) months. Mean preoperative annulus diameter of 29.7 ± 2.8 (23.8-37.8) mm was significantly reduced to 22.7 ± 2.9 (16.7-31.7) mm, P.001 at discharge and increased to 23.8 ± 2.3 (20.9-27.0) mm, P = .037 during follow-up. The mild increase in postoperative annulus diameter did not correlate with the reoccurrence of aortic insufficiency ≥2. Preoperative annulus was significantly larger in the external group (external: 30.6 ± 3.2 mm; internal: 29.1 ± 2.5 mm; P = .032). However, we found no significant difference in postoperative annulus increase rate between both techniques.Although mild, a significant continuous increase of annulus diameter after suture annuloplasty was seen, which did not correlate with the reoccurrence of aortic insufficiency ≥2 at mid-term follow-up. Annulus redilatation was comparable between external and internal technique.

We are currently witnessing rapid evolution in minimally invasive surgical- (MI-AVS) and transcatheter (TAVR) techniques and innovations for the treatment of aortic valve disease. Current TAVR technology approved for the treatment of aortic valve stenosis do not consistently perform favourably in non-calcified aortic valve regurgitation (AR). Surgical aortic valve repair (AVr) by conventional midline sternotomy is generally accepted as the contemporary "gold standard" intervention, while prosthetic aortic valve replacement and the wellknown Ross procedure as a biological alternative to AVr, are reserved for patients who are at risk of early repair failure. AVr offers potential benefits over prosthetic replacement in younger patients with contraindications to long term anticoagulation and life-expectancies greater than the expected structural prosthetic valve degeneration. Even though excellent AVr outcomes are achieved in high-volume expert centres, it is generally regarded to be technically challenging, have significant learning curves and is subsequently infrequently performed by inexperienced surgeons. MI-AVS, however, is now the routine approach for isolated aortic valve surgery in various cardiac centres and reports that describe minimally invasive AVr outcomes are progressively emerging. This article outlines the current role and future perspectives of contemporary AR repair techniques by MI-AVS and describe the ongoing evolution of exciting TAVR technology designed specifically for the treatment of non-calcified AR.

In the past decade, the treatment of aortic regurgitation has evolved from a strategy focused mainly around valve replacement to one of valve repair (AVr). Nevertheless, AVr has yet to gain broad acceptance within the surgical community despite excellent reported results in selected centers. In fact, AVr failure due to recurrence of regurgitation remains a challenge. Thanks to sustained research efforts, the mechanisms underlying aortic valve repair failure are now better understood. The aim of this article is to discuss the risk factors for recurrent AR after valve repair, the technical strategies that can mitigate this risk and highlight the contemporary results associated with AVr.

INTRODUCTION: This study evaluated surgical outcomes of infective endocarditis (IE), with particular attention to the impact of intravenous drug use (IVDU). METHODS: Adult patients undergoing surgery for IE between 2011 and 2018 at a single center were included and stratified by IVDU. The primary outcome was overall survival. Secondary outcomes included postoperative complications and hospital readmissions. Kaplan-Meier and multivariable Cox regression were utilized for unadjusted and risk-adjusted survival analyses, respectively. Cumulative incidence function curves were compared for hospital readmissions. RESULTS: A total of 831 patients (mean age 55 years, 34.4% female) were operated on for IE, including 318 (38.3%) with IVDU. Cultures were most commonly positive for streptococcus (25.2%), methicillin-sensitive Staphylococcus aureus (17.7%), enterococcus (14.3%), or methicillin-resistant Staphylococcus aureus (8.4%). The most common procedures included isolated aortic valve repair/replacement (18.8%), aortic root replacement (15.9%), mitral valve repair/replacement (26.7%), aortic and mitral valve replacement (8.4%), and tricuspid valve repair/replacement (7.6%). Mean follow-up was 3.4 ± 2.4 years. Overall 5-year survival was 64% and was similar between IVDU and non-IVDU. Multivariable analysis demonstrated that IVDU was not associated with mortality risk. IVDU patients displayed higher rates of all-cause readmission (61.6% vs 53.9%; P = .03), drug-use readmission (15.4% vs 1.4%; P < .001), and recurrent endocarditis readmission (33.0% vs 13.0%; P < .001). CONCLUSIONS: The majority of patients undergoing surgical treatment of IE are alive at 5-years although readmission rates are high. IVDU is not a risk factor for longitudinal mortality although patients with IVDU are at higher overall readmission risk, driven largely by greater readmissions for drug-use and recurrent endocarditis.

A 41-year-old woman was referred to tertiary cardiothoracic surgery centre following embolisation of the Amplatzer patent foramen ovale (PFO) closure device to septal leaflet of tricuspid valve with reopening of PFO. Two years earlier, she presented with thalamic stroke, and she was found to have a PFO following investigations. The following year she underwent transcatheter closure. Six months after the percutaneous closure, she presented again with significant periods of shortness of breath. Imaging studies revealed the migration and embolisation of PFO closure device to the septal leaflet of tricuspid valve with reopening of the foramen and significant tricuspid valve regurgitation. She underwent open heart surgery using cardiopulmonary bypass for retrieval of the device, closure of the foramen and repair of the tricuspid valve. The patient recovered well without any significant issues following surgery.

A 74-year old female patient presented with a 3-week history of fever, general weakness, and later developed complete heart block. On admission, the patient was febrile (temperature of 39°C) and tachypnoeic (respiratory rate of 29/min) with oxygen saturation of 95% on 2 L of oxygen. Her heart rate was 60 beats/min (VVI pacing), arterial blood pressure was 135/60 mm Hg and the Glasgow Coma Scale was 15. On chest auscultation, she had a harsh systolic murmur over her left precordium and bilateral rales. Blood tests demonstrated moderate anemia (hemoglobin of 95 g/L), leucocytosis (white blood cell count of 13.13 x 10^9/L), hypoalbuminemia (albumin concentration of 18 g/L), normal liver function tests and creatinine clearance of 45 ml/min. Computed tomography aortography demonstrated an irregular mass arising from the aortic root that extended into the right atrium (RA) and a fistulous tract (the Gerbode defect) between the left ventricular outflow tract (LVOT) and the right ventricle (RV). Transoesophageal echocardiography showed large vegetation in the RA and left to right cardiac shunt through the Gerbode defect from the LVOT to the RA and the RV. Using cardiopulmonary bypass, the patient underwent resection of the aortic cusps, debridement of the aortic root, septal and anterior leaflets of the tricuspid valve, and the membranous septum. The Gerbode defect was closed with an autologous pericardial patch, then a sliding annuloplasty of the septal leaflet of the tricuspid valve was performed. Finally, the aortic root was replaced with a 23 mm Freestyle xenograft.

Tricuspid valve regurgitation is associated with significant morbidity and mortality. Its most common treatment option, tricuspid valve annuloplasty, is not optimally effective in the long-term. Toward identifying the causes for annuloplasty’s ineffectiveness, we have previously investigated the technique’s impact on the tricuspid annulus and the right ventricular epicardium. In our current work, we are extending our analysis to the anterior tricuspid valve leaflet. To this end, we adopted our previous strategy of performing DeVega suture annuloplasty as an experimental methodology that allows us to externally control the degree of cinching during annuloplasty. Thus, in ten sheep we successively cinched the annulus and quantified changes to leaflet motion, dynamics, and strain in the beating heart by combining sonomicrometry with our well-established mechanical framework. We found that successive cinching of the valve enforced earlier coaptation and thus reduced leaflet range of motion. Additionally, leaflet angular velocity during opening and closing decreased. Finally, we found that leaflet strains were also reduced. Specifically, radial and areal strains decreased as a function of annular cinching. Our findings are critical as they suggest that suture annuloplasty alters the mechanics of the tricuspid valve leaflets which may disrupt their resident cells’ mechanobiological equilibrium. Long-term, such disruption may stimulate tissue maladaptation which could contribute to annuloplasty’s sub-optimal effectiveness. Additionally, our data suggest that the extent to which annuloplasty alters leaflet mechanics can be controlled via degree of cinching. Hence, our data may provide direct surgical guidelines.

Valvular atrial fibrillation (AF) is defined as AF in the presence of mitral stenosis or mechanical valve prosthesis. However, there are patients with AF who have significant native valvular heart disease (VHD) others than mitral stenosis that are classified as nonvalvular AF. The characteristics and prognostic implications of these entities have not been extensively studied. Of 1,885 AF patients referred for electrical cardioversion (64 +/- 13years, 71% male), 171 (9.1%) had valvular AF (any grade of mitral stenosis or mechanical/biological valve prostheses) and 1,714 patients were identified as nonvalvular AF, of whom 329 (17.5%) had significant left-sided VHD. Patients with nonvalvular AF but with significant left-sided VHD were older, more frequently women and had more co-morbidities compared with the other groups. Furthermore, nonvalvular AF patients with significant left-sided VHD showed the worst left ventricular systolic function and largest left atrial volumes. During a median follow-up of 64 months (interquartile range: 33 to 96 months), 488 patients presented with the combined endpoint of all-cause mortality, heart failure hospitalization, and ischemic stroke. Patients with nonvalvular AF and with significant left-sided VHD had more events of heart failure whereas patients with valvular AF had higher all-cause mortality events. There were no differences in ischemic stroke events. Type of AF was not associated with outcomes after correcting for echocardiographic variables. In conclusion, the frequency of AF patients with significant VHD is relatively high. The consequences of VHD and AF on cardiac structure and function are more important determinants of adverse outcome than the type of AF. (C) 2020 Elsevier Inc. All rights reserved.

BACKGROUND Significant secondary tricuspid regurgitation, often accompanied by right ventricular dilation and dysfunction, occurs in a significant proportion of patients submitted to surgery for severe mitral valve disease. It appears a vicious circle that is not interrupted by the treatment of the left heart valve alone, hence it requires concomitant intervention on the tricuspid valve. AIMS In this commentary I will discuss a paper published in this issue of the Journal by Calafiore et al from Riyadh - Saudi Arabia, reporting a retrospective study that evaluated the influence of preoperative right ventricular and tricuspid valve (TV) remodeling on the fate of tricuspid annuloplasty (TA) and RV in 423 patients undergoing TA for functional TR operated on from May 2009 to December 2015 at their institution. MATERIALS & METHODS Current guidelines and other consensus documents recommend that tricuspid valve surgeryshould be considered (class IIa) in patients with mild/moderate secondary regurgitation and/or significant annular dilatation. However, rates of tricuspid annuloplasty performed during operations to left-heart valves are very variable, depending also on the etiology of the mitral disease. RESULTS & DISCUSSION Different methods of annuloplasty are used by the surgical community - suture, rings, bands - with widely variable results with regard to the recurrence of regurgitation and long-term survival. Not all these techniques are standardised and this may also be a cause for the disparate results. CONCLUSION In the absence of randomized studies, which are highly unlikely to be undertaken in this situation, more information is required from large series with longer follow-ups.

Tricuspid regurgitation (TR) is a prevalent disease with limited treatment options.This is the first 30-day report of the U.S. single-arm, multicenter, prospective CLASP TR early feasibility study of the PASCAL transcatheter valve repair system in the treatment of TR.Patients with symptomatic TR despite optimal medical therapy, reviewed by the local heart team and central screening committee, were eligible for the study. Data were collected at baseline, discharge, and the 30-day follow-up and were reviewed by an independent clinical events committee and echocardiographic core laboratory. Feasibility endpoints included safety (composite major adverse event [MAE] rate), echocardiographic, clinical, and functional endpoints.Of the 34 patients enrolled in the study, the mean age was 76 years, 53% were women, the mean Society of Thoracic Surgeons score was 7.3%, 88% had atrial fibrillation/flutter, 97% had severe or greater TR, and 79% had New York Heart Association (NYHA) functional class III/IV symptoms. Twenty-nine patients (85%) received implants; at 30 days, 85% of them achieved a TR severity reduction of at least 1 grade, with 52% with moderate or less TR (p 0.001). The MAE rate was 5.9%, and none of the patients experienced cardiovascular mortality, stroke, myocardial infarction, renal complication, or reintervention. Eighty-nine percent of the patients improved to NYHA functional class I/II (p 0.001), the mean 6-min walk distance improved by 71 m (p 0.001), and the mean Kansas City Cardiomyopathy Questionnaire score improved by 15 points (p 0.001).In this early experience, the repair system performed as intended, with substantial TR reduction, favorable safety results with a low MAE rate, no mortality or reintervention, and significant improvements in functional status, exercise capacity, and quality of life. (Edwards CLASP TR EFS [CLASP TR EFS]; NCT03745313).

The Fontan procedure has provided patients with single ventricle physiology extended survival into adulthood and in many cases has improved their quality of life. Atrioventricular valve regurgitation ( AVVR ) is common in single ventricle patients and is associated with increased risk of mortality. AVVR is more common in patients with a systemic tricuspid or common atrioventricular valve but is generally progressive irrespective of underlying valve morphology. AVVR can be attributable to diverse structural and functional abnormalities at multiple levels of the valvar apparatus, as well as ventricular dysfunction and dilation. Multiple imaging modalities including recent advances in 3‐dimensional echocardiography and cross‐sectional imaging have been used to further understand AVVR . Surgery to address AVVR must be tailored to the underlying mechanism and the timing of surgical repair should be chosen carefully. In this review, we discuss the etiologies, treatment options, surgical timing, and outcomes of valve repair or replacement for AVVR in patients with single ventricle congenital heart disease, with a focus on those with a Fontan circulation as AVVR is associated with increased risk for Fontan failure and mortality. In‐depth understanding of the current literature will help guide clinicians in their approach and management of AVVR in this population.

ObjectivesTricuspid valve disease is increasingly encountered, but surgery is rarely performed in isolation, in part because of a reported higher operative risk than other single-valve operations. Although guidelines recommend valve repair, there is sparse literature for the optimal surgical approach in isolated tricuspid valve disease. We performed a meta-analysis examining outcomes of isolated tricuspid valve repair versus replacement.MethodsWe searched Pubmed, Embase, Scopus and Cochrane from January 1980 to June 2019 for studies reporting outcomes of both isolated tricuspid valve repair and replacement, excluding congenital tricuspid aetiologies. Data were extracted and pooled using random-effects models and Review Manager 5.3 software.ResultsThere were 811 article abstracts screened, from which 52 full-text articles reviewed and 16 studies included, totalling 6808 repairs and 8261 replacements. Mean age ranged from 36 to 68 years and females made up 24%–92% of these studies. Pooled operative mortality rates and odds ratios (95% confidence intervals) for isolated tricuspid repair and replacement surgery were 8.4% vs 9.9%, 0.80 (0.64 to 1.00). Tricuspid repair was also associated with lower in-hospital acute renal failure 12.4% vs 15.6%, 0.82 (0.72 to 0.93) and pacemaker implantation 9.4% vs 21.0%, 0.37 (0.24 to 0.58), but higher stroke rate 1.5% vs 0.9%, 1.63 (1.10 to 2.41). There were no differences in rates of prolonged ventilation, mediastinitis, return to operating room or late mortality.ConclusionIsolated tricuspid valve repair was associated with significantly reduced in-hospital mortality, renal failure and pacemaker implantation compared with replacement and is therefore recommended where feasible for isolated tricuspid valve disease, although its higher stroke rate warrants further research.

Purpose To analyze the efficacy of minimally invasive beating heart technique for mitral valve surgery in the cardiac patients with previous sternotomy and giant left ventricle. Methods Eighty cardiac patients with previous sternotomy and giant left ventricle according to the diagnostic criteria that left ventricular end diastolic diameter (LVEDD) was ≥70 mm, who underwent mitral valve surgery at our center from January 2006 to January 2019 were analyzed. We divided all patients into minimally invasive beating heart technique group (n = 30) and conventional median resternotomy arrested heart technique group (n = 50) according to the surgical methods. Preoperative, intraoperative, and postoperative variables were compared between two groups. Results Minimally invasive beating heart technique compared to the conventional median resternotomy arrested heart technique for mitral valve surgery in the cardiac patients with previous sternotomy and giant left ventricle had significant differences in operation time(P = 0.002), cardiopulmonary bypass (CPB) time(P P P = 0.01), postoperative transfusion amount(P P = 0.001), extubation time(P = 0.04), intensive care unit (ICU) stay time(P = 0.04) and postoperative hospital stay time(P Conclusions Using the method of minimally invasive beating heart technique for mitral valve surgery in the cardiac patients with previous sternotomy and giant left ventricle is effective and reliable, meanwhile reduce the operation time and CPB time, decrease the transfusion ratio and transfusion amount, shorten postoperative ICU stay and hospital stay time, promote the early extubation so that accelerate the patients’ early recovery. All of these show a benefit of minimally invasive beating heart technique compared to conventional median resternotomy arrested heart technique.

Tricuspid regurgitation (TR) is a frequent and complex problem, commonly combined with left-sided heart disease, such as mitral regurgitation. Significant TR is associated with increased mortality if left untreated or recurrent after therapy. Tricuspid regurgitation was historically often disregarded and remained undertreated. Surgery is currently the only Class I Guideline recommended therapy for TR, in the form of annuloplasty, leaflet repair, or valve replacement. As growing experience of transcatheter therapy in structural heart disease, many dedicated transcatheter tricuspid repair or replacement devices, which mimic well-established surgical techniques, are currently under development. Nevertheless, many aspects of TR are little understood, including the disease process, surgical or interventional risk stratification, and predictors of successful therapy. The optimal treatment timing and the choice of proper surgical or interventional technique for significant TR remain to be elucidated. In this context, we aim to highlight the current evidence, underline major controversial issues in this field and present a future roadmap for TR therapy.